The Best Of The Dish Today

I want to revisit the posts on Ponnuru’s and Levin’s critique of the Affordable Care Act – including my citing the obvious comparisons with other Western countries. Why is socialism so damn more efficient than capitalism when it comes to healthcare? I think the answer is a relatively simple one, and it was elegantly made by a commenter on Yuval’s piece at NRO. Money quote:

The root of “conservative” thinking on healthcare, at least as it is articulated in this space, appears not to have anything to do with centralization versus decentralization of decision making, but with dedication to the proposition that the healthcare market is just like all other markets; that a decision about healthcare follows the same logic and has the same degrees of freedom as do decisions such as whether to buy a new TV, or broccoli. Unless that catastrophically mistaken idea is abandoned, I don’t see how the local variety of “conservative” thinking can address reality and thereby improve.

The reason that the breadth of options that insurers can offer must be constrained is that if it is not constrained, then that variable, and not efficiency, is the lever that will preferentially be used as the profit generating mechanism. What that means in the real world is that the poor will be poorly insured and the rich richly insured, with the same problems of free ridership and poor long term outcomes due to avoidance of preventive care that we have now … In other words, healthcare really is a different beast in that it cannot be effectively treated as though it were a completely free market at the policy level because it can never, in fact, behave like one. That is not an ideological framing but a hard, cold fact. Healthcare is not a market like other markets and it is not even remotely anti free-market to point that out.

That‘s what I’m grappling with. The reason for my support for the ACA is that the crisis of costs and accessibility is urgent and only Obama had the balls to propose a possible solution. The ACA, it seems to me, is a good faith attempt at integrating the existing structures of American healthcare into a better system that can expand coverage and also control costs. In that sense, once again, I think Obama is the conservative in this – and many ideological liberals will not disagree. It may be that this conservative compromise won’t work; but a more bare bones insurance regime which does not have to include the basic needs of most lives, and skimps on preventative care, is a false economy.

There are cost control ideas embedded in the ACA. But I’d add some more conservative ingredients to the mix. I’d make co-pays a fixed percentage of the actual costs, not a flat fee, so that patients are brought closer to the actual price of what they want, and can adjust. I’d insist that all those about to get Medicare or care on the ACA exchanges also make a choice: whether to seek unlimited care at the very end of their lives or give someone else a power of attorney if they are incapacitated. Personally, I’d gladly make the choice not to survive for another few days if it would make it much more fiscally feasible for a child to get vaccinated. I consider that personally a moral imperative. But I’d still insist this remain a choice. And I’d face down the moronic denialism of “death panels”. Sane cost-controls in the most expensive time of our lives is not totalitarianism. It’s fiscal sanity and moral prudence. I’m used to facing down Sarah Palin and she knows it. I’d also be more stringent about tort reform than the ACA, though I have no illusions this is a panacea for the cost problem.

If you want a free market in healthcare, you have to let people die on the streets or in agony at home rather than seeking mandatory help in an emergency room, if they have not been able to buy insurance. Anything else is socialized medicine, which we’ve had in America since 1986. The question is simply whether we want to have the most fucked-up, inefficient and inhumane socialized system on the planet or whether we have the political courage to tackle this. Decry Obama all you like, but he has tackled this. And the pile-on is a form of denial that we have a problem. But boy, do we have a problem.